Postoperative pain management: epidural analgesia

BACKGROUND: Epidural analgesia is one of the most effective regimens for postoperative pain relief after abdominal surgery. The use of epidural analgesia in high risk patients has been associated with significant decrease in surgical stress response, in cardiac and pulmonary morbidity, in recovery of gastrointestinal function and in thromboembolic events. The aim of this paper is to describe pain relief, side effects and recovery of gastrointestinal function during epidural analgesia. METHODS: During the period January 1999 to September 2001, 590 patients undergoing elective major abdominal surgery received epidural analgesia. Epidural catheters were inserted at T8-T9 (upper abdominal surgery) or T9-T11 (lower abdominal surgery) and ropivacaine 0.5% ml 7-12 combined with sufentanil 30 microg or with morphine 2 mg was injected. General anesthesia was induced and a continuous epidural infusion of ropivacaine 0.5% 5-10 ml/h was begun. Postoperatively, continuous epidural administration of ropivacaine 0.2% plus sufentanil 0.5 microg/ml or ropivacaine 0.2% plus morphine 0.02 mg/ml was continued. Data on the quality of analgesia, recovery of gastrointestinal function and all side effects were recorded for 4 days. RESULTS: Resting and incident pain scores were <4 and <5; 20% of patients received a rescue dose; the incidence of nausea was 6%, pruritus 5%; all patients also recovered from postoperative ileus. CONCLUSIONS: Continuous epidural analgesia resulted in good pain relief, provided the best balance of analgesia and side effects and improved postoperative outcome.     

What concentration of sufentanil should be combined with ropivacaine 0.2% wt/vol for postoperative patient-controlled epidural analgesia?

In this randomized double-blinded study, we sought to determine an optimal dose-combination of sufentanil with ropivacaine 0.2% wt/vol as postoperative epidural analgesics. One hundred twenty patients undergoing major abdominal surgery under general and thoracic epidural anesthesia (T9-11) were assigned to groups receiving patient-controlled epidural analgesia with ropivacaine 0.2% wt/vol (R), ropivacaine 0.2% wt/vol + sufentanil 0.5 microg/mL (R+S0.5), 0. 75 microg/mL (R+S0.75), 1.0 microg/mL (R+S1). A visual analog score of less than 40 was considered effective, and all side effects were recorded. In randomized subgroups (10 patients per group), plasma pharmacokinetic data were obtained for both epidural drugs. Four patients in Group R and two in Group R+S0.5 were excluded because of inadequate analgesia. The drug infusion rates (range of means: 5.4-5. 9 mL/h) were similar in all patients. Analgesia was superior for sufentanil 0.75 microg/mL with no further enhancement by the larger sufentanil concentration of 1 microg/mL. Sufentanil plasma levels were within the range of the minimal effective concentrations (highest in R+S1), and there was no covariation between plasma levels and pain relief. Free ropivacaine plasma concentrations remained stable for 96 h. No severe side effects were detected, although pruritus correlated with an increasing dose of sufentanil. We conclude that the combination of ropivacaine 0.2% wt/vol and 0.75 microg/mL sufentanil provided the best analgesia with the fewest side effects of the three combinations tested. IMPLICATIONS: Sufentanil is added to epidural infusions of ropivacaine 0.2% wt/vol to improve the effectiveness of postoperative pain management. Regarding the risk of side effects, however, it is still unclear what concentration of sufentanil should be added to the local anesthetic. For postoperative thoracic epidural analgesia after major abdominal surgery, the combination of ropivacaine 0.2% wt/vol and 0.75 microg/mL sufentanil resulted in an appropriate cost:benefit ratio between good analgesia and side effects.     

Patient-controlled epidural analgesia after abdominal surgery: ropivacaine versus bupivacaine.

In this randomized, double-blinded study we sought to assess the analgesic efficacy of ropivacaine and bupivacaine in combination with sufentanil and the efficacy of ropivacaine alone after major abdominal surgery. Sixty patients undergoing major abdominal surgery received standardized general anesthesia combined with epidural thoracic analgesia. They were allocated to one of three groups: the BS group received postoperative patient-controlled epidural analgesia with 0.125% bupivacaine plus 0.5 microg/mL sufentanil; the RS group received 0.125% ropivacaine plus 0.5 microg/mL sufentanil; and the R group received 0.2% ropivacaine, with the patient-controlled epidural analgesia device set at bolus 2-3 mL and background infusion 3-5 mL/h. Visual analog scale scores were significantly lower during coughing in the BS group compared with the RS and R groups and in the RS group compared with the R group. The BS group required significantly less local anesthetic (milligrams per day) during the first three postoperative days compared with the RS and R groups, and the RS group, significantly less than the R group. No major side effects were noted in any group. We conclude that, after major abdominal surgery, thoracic epidural analgesia was more effective with bupivacaine than with ropivacaine when these two local anesthetics are used in a mixture with sufentanil. Ropivacaine alone was less effective than ropivacaine in combination with sufentanil. IMPLICATIONS: After major abdominal surgery, thoracic epidural analgesia was more effective with 0.125% bupivacaine than with 0.125% ropivacaine when these two local anesthetics were used in a mixture with 0.5 microg/mL sufentanil. Ropivacaine 0.2% alone was less effective than 0.125% ropivacaine combined with sufentanil.     

Postoperative epidural analgesia after total knee arthroplasty with sufentanil 1 microg/ml combined with ropivacaine 0.2%, ropivacaine 0.125%, or levobupivacaine 0.125%: a randomized, double-blind comparison

BACKGROUND AND OBJECTIVES: Total knee replacement is associated with severe postoperative pain that, if treated insufficiently, interferes with early rehabilitation. The purpose of the present study is to compare the efficacy of ropivacaine (0.2% and 0.125%) and levobupivacaine (0.125%), all in combination with sufentanil 1 microg/mL with regard to postoperative pain relief and absence of motor block in a patient-controlled epidural analgesia setting. METHODS: The study design was randomized and double-blind. Sixty-three patients scheduled for total knee replacement under combined spinal-epidural anesthesia were randomly allocated to receive ropivacaine 0.2%/sufentanil 1 microg/mL (group 1), ropivacaine 0.125%/sufentanil 1 microg/mL (group 2), or levobupivacaine 0.125%/sufentanil 1 microg/mL (group 3) for postoperative epidural pain relief. Primary endpoints were numerical rating scores for pain and patient satisfaction, motor block scores, time to first demand of the patient-controlled epidural analgesia device and average hourly consumption of local anesthetic and sufentanil. RESULTS: There were no significant differences between the 3 groups regarding numerical rating scores for pain, patient satisfaction, and motor block scores at any of the time intervals; time to first demand and average hourly sufentanil consumption were similar. Patients in group 1 used significantly more local anesthetic than patients in groups 2 and 3. CONCLUSIONS: All 3 solutions provided adequate analgesia and minimal motor block. The higher concentration of ropivacaine 0.2% was associated with a higher consumption of local anesthetic and did not result in a decrease in the consumption of sufentanil. Under the conditions of this study, patient-controlled epidural analgesia consumption of the epidural mixture was predominantly determined by sufentanil.     

A comparison of five solutions of local anaesthetics and/or sufentanil for continuous, postoperative epidural analgesia after major urological surgery.

BACKGROUND AND OBJECTIVE: The aim of the present study was to compare and assess the quality of analgesia, the safety and the side-effects after the use of a continuous, thoracic epidural infusion of sufentanil (5 microg h(-1)), 0.25% bupivacaine (10 mL h(-1)), 0.2% ropivacaine (10 mL h(-1)) alone or in combination in patients who had undergone major urological surgery. This prospective, randomized, double-blinded study investigated the efficacy of thoracic epidural infusions after major urological surgery. METHODS: Patients received a 72-h continuous infusion (10 mL h(-1)) of 0.25% bupivacaine (B), 0.2% ropivacaine (R), 0.25% bupivacaine with 0.5 microg mL(-1) sufentanil (BS), 0.2% ropivacaine with 0.5 microg mL(-1) sufentanil (RS) or 0.5 microg mL(-1) sufentanil only (S). The analysis included 109 patients. RESULTS: The mean visual analogue scale (VAS) scores for pain were highest in the groups R and S (P < 0.001). The PaCO2 values were significantly higher in the groups RS and S (P = 0.003). Motor block occurred more frequently in the groups B and BS than in the other groups (P < 0.001). Sedation, nausea and pruritus were more common in the groups that received sufentanil. CONCLUSIONS: A continuous, epidural infusion with these drugs was safe and effective in our patients. The combination of 0.2% ropivacaine plus sufentanil appeared preferable because of the low incidence of motor block.     

Comparison of continuous background infusion plus demand dose and demand-only parturient-controlled epidural analgesia (PCEA) using ropivacaine combined with sufentanil for labor and delivery

BACKGROUND: Using ropivacaine combined with sufentanil, we determined the analgesic efficacy of parturient-controlled epidural analgesia (PCEA) with or without (demand-only PCEA) continuous background infusion in reducing labor pain in 66 parturients. METHODS: After placement of the epidural catheter and administration of an initial bolus containing ropivacaine 16 mg and sufentanil 10 microg, parturients were prospectively randomized into two groups. The PCEA solution consisted of ropivacaine 0.16% plus sufentanil 0.5 microg/mL. Parturients with PCEA plus continuous background infusion received 4 mL/h plus an hourly maximum of three 4-mL boluses on demand (lock-out time 20 min); parturients with demand-only PCEA received an hourly maximum of four 4-mL boluses (lock-out time 15 min) of anesthetic solution. Pain scores (VAS 0-100 mm), drug doses administered, duration of labor, sensory and motor epidural block characteristics, maternal satisfaction, neonatal outcome and adverse events were determined. RESULTS: Both regimens provided excellent parturients' satisfaction and pain relief. However, periods of VAS scores>40 mm during all stages of labor were significantly more frequent in parturients receiving demand-only PCEA (22.4%) compared to parturients receiving PCEA plus continuous background infusion (7.5%, P=0.0011). Drug doses administered, duration of PCEA, labor and delivery, epidural block characteristics, neonatal outcome and adverse events did not differ between groups. CONCLUSION: Under the conditions of the study, PCEA plus continuous background infusion was more effective than demand-only PCEA in treating labor pain without increasing consumption of anesthetic solution.     

Ropivacaine 0.15% plus sufentanil 0.5 microg/mL and ropivacaine 0.10% plus sufentanil 0.5 microg/mL are equivalent for patient-controlled epidural analgesia during labor

We compared the administration of 0.15% ropivacaine plus 0.5 microg/mL of sufentanil with that of 0.10% ropivacaine plus 0.5 microg/mL of sufentanil for labor analgesia with patient-controlled epidural analgesia (PCEA) to determine whether a decreased concentration of ropivacaine could produce equally effective analgesia. One-hundred-thirty healthy pregnant women at term were randomized in a double-blinded fashion. The PCEA settings were as follows: 12-mL initial bolus, 5-mL bolus dose, 5-min lockout interval, and 10 mL/h basal infusion. Patient demographics and labor characteristics were comparable in both groups. No differences were observed for pain scores, maternal satisfaction, volume of anesthetic solution administered, number of boluses requested and delivered, need for supplemental boluses, mode of delivery, motor block, side effects, or Apgar scores. Patients in the 0.10% ropivacaine group used significantly less drug than those in the 0.15% group (mean, 57 mg; 95% confidence interval, 50.5-63.5 mg; versus mean, 88.0 mg; 95% confidence interval, 74.4-93.3 mg, respectively; P < 0.0001). Ropivacaine 0.10% plus 0.5 microg/mL of sufentanil administered via PCEA for labor analgesia is equally effective as ropivacaine 0.15% plus 0.5 microg/mL of sufentanil, with a 30% local anesthetic-sparing effect and a 40% reduction in cost. However, this reduction in local anesthetic is not associated with a decrease in the incidence of motor block, side effects, or instrumental deliveries. IMPLICATIONS: Ropivacaine 0.10% plus 0.5 microg/mL of sufentanil given via patient-controlled epidural anesthesia for labor analgesia is equally as effective as ropivacaine 0.15% plus 0.5 microg/mL of sufentanil, with a 30% local anesthetic-sparing effect and a 40% reduction in cost. This reduction in ropivacaine concentration is not associated with a decrease in the incidence of motor block, side effects, or instrumental deliveries.     

Epidural analgesia in abdominal surgery: 0.2% ropivacaine with sufentanil

AIM: Combining an opioid with peridural local analgesia is an excellent technique to control post-operative pain. Sufentanil is a widely used opioid agent, but its optimal dosage has not yet been defined. In this study we wanted to determine the best dose of epidural sufentanil in major surgery. METHODS: Before the operation, 45 major abdominal surgery patients received blended anesthesia through an epidural chest catheter. The patients were randomized into 3 groups of 15 subjects according to different sufentanil doses [0.2% ropivacaine combined with sufentanil at a dose of 0.5 microg/ml(-1), 0.75 microg/ml(-1), or 1 microg/ml(-1) (groups A, B and C, respectively)] administered through an epidural chest catheter connected to an elastometric pump (5 ml/h) for the first 36 postoperative hours. The level of postoperative analgesia in motion and at rest was measured using an analog visual scale (VAS-R, VAS-I). RESULTS: Analgesia was best in group A, and similar in groups B and C; 2 cases of pruritus were noted in group C. The VAS-I scores were <3 across all 3 patient groups. CONCLUSION: Epidural analgesia is an efficacious and reliable technique. The combination of 0.2% ropivacaine and 0.75 microg/ml(-1) sufentanil was found to be the optimum choice between analgesic efficacy and minor side effects, which correlated with the higher dose of sufentanil given to group C.     

The analgesic effect of sufentanil combined with ropivacaine 0.2% for labor analgesia: a comparison of three sufentanil doses

The combination of opioids with local anesthetics is commonly used for epidural labor analgesia. We examined whether increasing sufentanil in doses of 5, 10, and 15 microg prolonged the duration of labor analgesia produced by ropivacaine. One hundred healthy parturients in the first stage of labor who requested epidural analgesia were enrolled. Parturients were randomized to receive 12 mL ropivacaine 0.2% alone or with sufentanil 5 microg, sufentanil 10 microg, or sufentanil 15 microg. The duration of analgesia, pain score, degree of motor blockade (using a four-point Bromage scale), heart rate, blood pressure, respiratory rate, oxygen saturation, and incidence of nausea and pruritus were recorded. The mean duration of epidural analgesia was 96 +/- 32 min for patients without sufentanil, 134 +/- 27 min for Group 5 (p < 0.01 versus control), 135 +/- 33 min for Group 10 (p < 0.01 versus control), 130 +/- 33 min for Group 15 (p < 0.01 versus control) without differences among sufentanil groups. Between 30 and 90 min, the sufentanil groups (5 microg, 10 microg, and 15 microg) had lower pain scores than the control group (p < 0.01 versus control) but there were no differences among the sufentanil groups. No patient in any group had a Bromage score more than 1. No significant difference was found for opioid-related side effects. We conclude that 5-10 or 15 microg sufentanil induced a similar prolongation of analgesia when combined with ropivacaine 0.2% for initiation of labor analgesia. Implications: We studied the effect of adding one of three possible sufentanil doses to epidural ropivacaine 0.2% for labor analgesia. Adding sufentanil increased the duration of analgesia but there was no advantage in adding more than 5 microg of sufentanil.     

Epidural combination of ropivacaine with sufentanil for postoperative analgesia after total knee replacement: a pilot study

BACKGROUND AND OBJECTIVE: We assessed the analgesic efficacy of postoperative epidural infusions of ropivacaine 0.1 and 0.2% combined with sufentanil 1 microg mL(-1) in a prospective, randomized, double-blinded study. METHODS: Twenty-two ASA I-III patients undergoing elective total-knee replacement were included. Lumbar epidural blockade using ropivacaine 0.75% was combined with either propofol sedation or general anaesthesia for surgery. After surgery, the epidural infusion was commenced. Eleven patients in each group received either an epidural infusion of ropivacaine 0.1% with 1 microg mL(-1) sufentanil (Group 1) or ropivacaine 0.2% with 1 microg mL(-1) sufentanil (Group 2) at a rate of 5-9 mL h(-1). All patients had access to intravenous pirinatrimide (piritramide) via a patient-controlled analgesia (PCA) device. RESULTS: Motor block was negligible for the study duration in both groups. There was no significant difference with the 100 mm visual analogue scale (VAS) scores, with the consumption of rescue analgesia or with patient satisfaction. Patients in Group 1 experienced significantly less nausea (P < 0.05) than those in Group 2. Both treatment regimens provided effective postoperative analgesia with only a minimal use of supplemental opioid PCA. CONCLUSIONS: We recommend the use of ropivacaine 0.1% with 1 microg mL(-1) sufentanil for postoperative analgesia after total knee replacement as it provides efficient pain relief with no motor block of the lower limbs. In addition, compared with 0.2% ropivacaine with sufentanil, the mixture reduces local anaesthetic consumption without compromise in patient satisfaction or VAS scores. Patients even experience less nausea.     

Epidural analgesia during labor: intermittent bolus or patient controlled administration?

BACKGROUND: The aim of the study was to compare efficacy and side effects produced by two techniques of epidural analgesia during labor: intermittent bolus and patient-controlled epidural analgesia. METHODS: Eighty parturients were enrolled in this study: forty received intermittent bolus analgesia (first bolus: 20 mg of ropivacaine 0.1% + 10 gamma of sufentanil, next bolus: 10 mg of ropivacaine 0.1% during the first 4 hours, and then 10 mg of ropivacaine 0.1% + 2.5 gamma of sufentanil each time they complained of pain), and forty parturients received PCEA (starting with a bolus of 20 mg ropivacaine 0.1% + 10 gamma sufentanil, followed by administration with a pump programmed to deliver a continuous background infusion of ropivacaine 0,1% + 0.25 gamma/ml of sufentanil at 5 ml/h and 5 ml patient-triggered boluses with a 15 min lock-out interval; insufficient analgesia was treated by extra boluses of the same ropivacaine solution). In each group the efficacy of the analgesia (verbal numerical pain scores, amount of local anesthetics consumption), labor duration, side effects and patient satisfaction have been studied. RESULTS: There were no differences between the two different epidural techniques. CONCLUSIONS: This regimen of PCEA proves a viable and safe alternative for epidural analgesia during labor.     

The continuous epidural infusion of ropivacaine 0.1% with 0.5 μg·mL−1 sufentanil provides effective postoperative analgesia after total hip replacement: a pilot study

PURPOSE: To assess the analgesic efficacy and functional outcome of postoperative epidural infusion of ropivacaine combined with sufentanil in a randomized, controlled trial. METHODS: Thirty-two ASA I-III patients undergoing elective total hip replacement (THR) were included. Lumbar epidural block using 0.75% ropivacaine was combined with either propofol sedation or general anesthesia for surgery. On arrival in the recovery room, the epidural infusion was commenced at a rate in mL calculated as follows: (height in cm - 100) x 0.1. Eleven patients received an epidural infusion of ropivacaine 0.1% with 0.5 microg x mL(-1) sufentanil (Group R+S0.5), ten patients ropivacaine 0.1% with 0.75 microg x mL(-1) sufentanil (Group R+S0.75), and 11 patients ropivacaine 0.1% with 1 microg x mL(-1) sufentanil (Group R+S1) over a postoperative study period of 44 hr. All patients had access to iv piritramide via a patient-controlled analgesia (PCA) device. Postel-Merle-d'Aubigné scoring system (PMA score) was assessed preoperatively, three weeks after surgery, and three months after surgery by an orthopedic surgeon blinded to study group. RESULTS: Motor block was negligible in all three groups. After eight hours of epidural infusion, sensory block had regressed completely in all patients. There was no significant difference with regard to visual analogue scale (VAS) scores (at rest: P = 0.55, on movement: P = 0.63), consumption of rescue medication (P = 0.99), patient satisfaction (P = 0.22), and the incidence of adverse events. All treatment regimens provided effective postoperative analgesia with only a minimal use of supplemental opioid PCA. There was no difference between groups regarding orthopedic PMA score (pain: P = 0.24, mobility: P = 0.65, and ability to walk: P = 0.44). CONCLUSION: Ropivacaine 0.1% with 0.5 microg x mL(-1) sufentanil for postoperative analgesia after THR provides efficient pain relief and, compared with 0.75 and 1 microg x mL(-1) sufentanil, reduces sufentanil consumption without compromise in patient satisfaction, VAS scores, and functional outcome.     

Patient-controlled epidural analgesia versus continuous epidural infusion with ropivacaine for postoperative analgesia in children

Epidural ropivacaine infusion has been used in children; however, patient-controlled epidural analgesia (PCEA) has not been evaluated in the pediatric population. In this study, we compared the clinical efficiency of PCEA and of continuous epidural infusion analgesia (CEA) in children. Forty-eight children undergoing orthopedic surgery were randomized to receive PCEA or CEA with ropivacaine 0.2%. All patients underwent a standard general anesthetic. Children also received ketoprofen and propacetamol. Pain scores and side effects were recorded for 48 h. If the visual analog score scale score was >4 of 10, analgesia was considered inadequate, and rescue treatment was administered. Both groups obtained effective pain relief. Children in the PCEA group received significantly less local anesthetic than those in the CEA group (0.20 +/- 0.08 mg x kg(-1) x h(-1) versus 0.40 +/- 0.08 mg x kg(-1) x h(-1); P < 0.001). Motor effects, supplemental analgesic requirements, and side effects did not differ. We concluded that PCEA with ropivacaine 0.2% can provide adequate postoperative analgesia for pediatric orthopedic procedures with smaller dose requirements than CEA. IMPLICATIONS: We studied patient-controlled epidural analgesia (PCEA) and continuous epidural infusion analgesia (CEA) with 0.2% ropivacaine during the postoperative period in children. We found that either PCEA or CEA with plain ropivacaine 0.2% provided adequate pain relief in children during the first 48-h postoperative course. However, adequate analgesia was obtained with 50% less volume infused with PCEA compared with CEA.     

Comparison of continuous epidural infusion of ropivacaine and sufentanil with intravenous patient-controlled analgesia after total hip replacement.

We assessed the efficacy of an epidural infusion of ropivacaine 0.1% and sufentanil 1 microg x ml(-1), comparing it with intravenous patient-controlled analgesia using piritramide in this prospective, randomised, double-blind study of 24 ASA physical status I-III patients undergoing elective total hip replacement. Lumbar epidural block using ropivacaine 0.75% was combined with either propofol sedation or general anaesthesia for surgery. Epidural infusion and patient-controlled analgesia were started after surgery. Twelve patients received an epidural infusion of ropivacaine 0.1% and sufentanil 1 microg x ml(-1) at a rate of 5-9 ml x h(-1) and an intravenous patient-controlled analgesia device loaded with saline. Eleven patients received an epidural infusion of saline at the same rate and intravenous piritramide via the patient-controlled analgesia device. Motor block was negligible in both groups. The epidural ropivacaine group had significantly lower visual analogue pain scores at rest 4 h after surgery (p < 0.01), and on movement 4 h (p < 0.01) and 8 h (p < 0.05) after surgery, than the intravenous piritramide group. The piritramide group experienced significantly more adverse events than the epidural group (p < 0.001), especially hypotension (p < 0.01) and vomiting (p < 0.05). Patients in the epidural ropivacaine group were more satisfied with the pain management (p < 0.05). We conclude that the epidural infusion of ropivacaine 0.1% and sufentanil 1 microg x ml(-1) is superior to intravenous opioid by patient-controlled analgesia in preventing pain after total hip replacement, with fewer adverse effects and greater patient satisfaction.     

Safety and efficacy of patient controlled epidural analgesia following pediatric spinal surgery

BACKGROUND: Patient controlled epidural analgesia (PCEA) is uncommon in pediatric anesthesia. Because PCEA offers superior pain control compared with continuous epidural infusions in adults, we prospectively evaluated the analgesia efficacy and safety of PCEA in children and adolescents following extensive spinal surgery. METHODS: Following ethics committee approval, 100 consecutive children [age median (range) 14 (6-19) years] undergoing spinal surgery were studied until the seventh postoperative day, and 98 children received a PCEA. One or two epidural catheters were positioned under direct vision by the surgeon based on the number of vertebral segments operated upon. The epidural solution consisted of bupivacaine 0.0625%, fentanyl 1 microg.ml(-1) and clonidine 0.6 microg.ml(-1), delivered at a basal rate of 0.2 ml.kg(-1).h(-1) and a PCEA dose of 0.1 ml.kg(-1).h(-1)(max. 2 h(-1)). On the fourth postoperative day, PCEA was stopped and analgesia was continued with patient controlled analgesia (PCA) with morphine. RESULTS: During the PCEA regimen, the maximal scores of the revized facial scale were below 4 at rest with a very high satisfaction rate (>90%). Pain scores were higher during mobilization on the first postoperative day and when PCEA was switched to PCA. The overall incidence of adverse events was low and consisted primarily of technical problems and postoperative nausea and vomiting. Only two children experienced a complication requiring the discontinuation of the PCEA but there were no consequent adverse sequelae. CONCLUSIONS: The present study demonstrates that PCEA provides excellent pain relief following extensive spinal surgery and is associated with a low incidence of adverse events. The use of PCEA should be encouraged in children and adolescents following extensive spinal surgery.     

Pre-incisional epidural ropivacaine, sufentanil, clonidine, and (S)+-ketamine does not provide pre-emptive analgesia in patients undergoing major pancreatic surgery

BACKGROUND: The concept of pre-emptive analgesia remains controversial. This prospective, randomized, and double-blind study compared epidural administration of ropivacaine 2 mg ml(-1), sufentanil 0.5 microg ml(-1), clonidine 3 microg ml(-1), and S(+)-ketamine 0.25 mg ml(-1) (study solution) given before incision with the same combination started at the end of the operation. METHODS: After testing the stability of the solution using high performance liquid chromatography (HPLC) and examining 12 patients for possible side-effects in comparison with the epidural infusion of ropivacaine 2 mg ml(-1) and sufentanil 0.5 microg ml(-1), 30 patients undergoing major pancreatic surgery were recruited into the study. Before induction of anaesthesia, an epidural catheter was inserted (TH6-8). Patients in Group 1 received a bolus of 8 ml followed by a continuous infusion (8 ml h(-1)) of the study solution before induction of anaesthesia. In Group 2, patients received the same volume of saline before operation, the study solution was started at the end of surgery. After operation, the infusion was maintained for at least 96 h using a patient-controlled epidural analgesia (PCEA) pump in both groups. Patients were evaluated up to the seventh postoperative day for pain and side-effects. RESULTS: Visual analogue scale (VAS) values at rest were as follows: G1 vs G2: 24 h, 19 (sd 23) vs 6 (13); 48 h, 4 (10) vs 11 (21); and 72 h, 12 (22) vs 13 (21). VAS values during coughing and mobilization were also comparable. Total volume of epidural infusion was 904 (114) ml in G1 vs 892 (154) ml in G2. The incidence of side-effects (nausea, vomiting, and motor block) was low and not different between the groups. CONCLUSIONS: Pre-incisional epidural analgesic infusion did not provide pre-emptive analgesia compared with administration started at the end of surgery, but both groups had low pain scores.     

PCEA compared to continuous epidural infusion in an ultra-low-dose regimen for labor pain relief: a randomized study

BACKGROUND: Patient-controlled epidural analgesia, PCEA, has been introduced in obstetric analgesia during the past decade. Many studies have shown that the consumption of analgesic is reduced when the parturient requests her own doses. This study investigates whether this is also true when using an ultra-low-dose regimen. METHODS: Eighty parturients were prospectively randomized to have either continuous epidural infusion (CEI) with ropivacaine 1 mg ml-1 and sufentanil 0.5 micro g ml-1, 6 ml h-1, or patient-controlled epidural analgesia (PCEA) with 4 ml demand doses with 20 min' lockout. The epidural start dose was the same for the two groups, 8 ml of the study solution. Rescue bolus doses were given when needed and the continuous infusion could be increased, which gave the two groups the same maximum possible dose. The consumption of local ropivacaine in combination with sufentanil during labor was registered. Hourly assessments made throughout labor included pain intensity documented with visual analog score, VAS, the patient's opinion on epidural efficacy, motor block, pruritus and need for nitrous oxide. RESULTS: The PCEA group consumed 33% less of the study solution than the CEI group. Mean total consumption was 35 ml (SD 18.0) and 52 ml (SD 19.6), respectively. Mean hourly consumption was 5.2 ml h-1 (SD 2.54) in the PCEA group and 6.9 ml h-1 (SD 1.31) in the CEI group. There were no significant differences between the two groups in pain relief, epidural efficacy, side-effects or obstetric outcome. CONCLUSION: PCEA reduces doses compared to continuous infusion even when ultra-low-dose local anesthetic with opioid is used. The PCEA technique provides individual titration of doses to an acceptable degree of pain relief.     

Comparison of ropivacaine-fentanyl patient-controlled epidural analgesia with morphine intravenous patient-controlled analgesia for perioperative analgesia and recovery after open colon surgery

STUDY OBJECTIVE: To compare the effects of ropivacaine-fentanyl patient-controlled epidural analgesia (PCEA) with morphine intravenous (IV) patient-controlled analgesia (PCA). DESIGN: Prospective, randomized, multicenter trial. SETTING: Five university-affiliated hospitals. PATIENTS: 41 patients undergoing colon surgery. INTERVENTION: Patients were randomized to receive either standardized combined epidural/general anesthesia followed by PCEA with ropivacaine 0.2% and fentanyl (2 microg/mL) or standardized general anesthesia followed by morphine IV PCA. All patients participated in a standardized postoperative clinical pathway. MEASUREMENTS AND MAIN RESULTS: Analgesia was assessed with visual analog scale (VAS) scores. Postoperative recovery was assessed by completion of prospectively defined discharge milestones and time until discharge. Statistical analyses included nonparametric and contingency table analyses. The PCEA group had better analgesia (> 50% reduction in pain scores, assessed both at rest and during a cough) for the first 3 days after surgery (p < 0.0,005). The PCEA group achieved discharge milestones approximately 36 hours faster (p < 0.002), but time until discharge was similar between groups. CONCLUSIONS: Ropivacaine-fentanyl PCEA provides superior analgesia, reduced opioid requirement, and more rapid recovery after colon surgery.     

Patient-controlled epidural analgesia following combined spinal-epidural analgesia in labour: the effects of adding a continuous epidural infusion

Patient-controlled epidural analgesia (PCEA) is used to maintain epidural analgesia following initial intrathecal analgesia. This trial investigated whether a continuous background infusion with PCEA provides superior analgesia to PCEA alone among patients who received combined spinal-epidural (CSE) analgesia during labour Eighty parturients were randomized to either PCEA alone (PCEA) or PCEA with a background infusion of ropivacaine 0.15% with sufentanil 0.75 microg/ml at 2 ml/h (PCEA + CEI). PCEA settings were a bolus of 4 ml of the same analgesic solution with a lockout interval of 15 minutes. Significantly more patients in the PCEA group required at least one anaesthetist intervention for breakthrough pain (27 [71%] vs 10 [25%] in the PCEA + CEI group, P<0.05). Consumption of local anaesthetic (excluding manually administered boluses) was similar between the groups. If anaesthetist-administered boluses were included, more local anaesthetic was consumed by the PCEA group (47.1 +/- 19.4 mg vs 35.6 +/- 12.0 mg in the PCEA + CEI group, P<0.05). We conclude that PCEA with a background infusion provides effective analgesia with less anaesthetist workload and reduced local anaesthetic consumption as compared with PCEA without a background infusion.     

Patient-controlled epidural analgesia reduces analgesic requirements compared to continuous epidural infusion after major abdominal surgery

PURPOSE: To compare the quality of pain relief and incidence of side effects between 24-hr postoperative continuous epidural infusion (CEI) and subsequent patient-controlled epidural analgesia (PCEA) with different analgesics after major abdominal surgery. METHODS: Twenty-eight women undergoing extended gynecological tumour surgery received postoperative CEI with 0.15 mL x kg(-1) x hr(-1) 0.2% ropivacaine (R: n = 14) or 0.125% bupivacaine plus 0.5 micro g x mL(-1) sufentanil (BS: n = 14) during 24 postoperative hours. Twenty-four hours later, postoperative pain management was switched to PCEA without background infusion and 5 mL single bolus application of R or BS every 20 min at most. Visual analogue scales (VAS; 1-100 mm) were assessed by patients at rest and on coughing after 24 hr of CEI and PCEA. Side effects, doses of local anesthetics and opioids were recorded and plasma concentrations of total and unbound ropivacaine and bupivacaine were measured. RESULTS: Patients required lower doses of each respective analgesic medication with PCEA (R: 108 +/- 30 mL; BS: 110 +/- 28 mL) than with CEI (R: 234 +/- 40; BS: 260 +/- 45; P < 0.01). Ropivacaine plasma concentrations were lower 24 hr after PCEA when compared with CEI (P < 0.01). No patient after PCEA but two after CEI (n = 4; NS) presented motor block. PCEA with R provided better postoperative pain relief than CEI (37 +/- 32 vs 59+/-27, P < 0.05). No difference in parenteral opioid rescue medication between CEI and PCEA was seen. CONCLUSION: PCEA in comparison to preceding CEI provides equivalent analgesia with lower local anesthetic doses and plasma levels, and without motor blocking side effects, irrespective of the applied drug regimen.